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. 2013 May;2(3):247-60.
doi: 10.3978/j.issn.2225-319X.2013.05.06.

A systematic review and meta-analysis of hybrid aortic arch replacement

Konstantinos G Moulakakis  1 , Spyridon N Mylonas, Fotis Markatis, Thomas Kotsis, John Kakisis, Christos D Liapis
Affiliations

A systematic review and meta-analysis of hybrid aortic arch replacement

Konstantinos G Moulakakis et al. Ann Cardiothorac Surg. 2013 May.

Abstract

Background: Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies.

Methods: Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality.

Results: Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort.

Conclusions: Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.

Keywords: Aortic arch; debranching; frozen elephant trunk; hybrid; stented elephant trunk.

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Figures

Figure 1
Figure 1
Hybrid aortic arch repair
Figure 2
Figure 2
Study flow diagram. Forty-six publications were included in the analysis. AD, arch debranching group; ET, elephant trunk group
Figure 3
Figure 3
Forest plot of technical success rate in the arch debranching group. AD, arch debranching
Figure 4
Figure 4
Forest plot of mortality rate in the arch debranching group. AD, arch debranching
Figure 5
Figure 5
Forest plot of stroke rate in the arch debranching group. AD, arch debranching
Figure 6
Figure 6
Forest plot of irreversible spinal cord injuries in the arch debranching group. AD, arch debranching
Figure 7
Figure 7
Forest plot of renal failure requiring dialysis in the arch debraching group. AD, arch debranching
Figure 8
Figure 8
Forest plot of mortality rate in the elephant trunk group. ET, elephant trunk
Figure 9
Figure 9
Forest plot of stroke rate in the elephant trunk group. ET, elephant trunk
Figure 10
Figure 10
Forrest plot of irreversible spinal cord injuries in the elephant trunk group. ET, elephant trunk
Figure 11
Figure 11
Forrest plot of renal failure requiring dialysis in the elephant trunk group. ET, elephant trunk
Figure S1
Figure S1
Forrest plot of retrograde dissection in AD Group. AD, arch debranching
Figure S2
Figure S2
Forrest plot of need for cardiac support in AD Group. AD, arch debranching
Figure S3
Figure S3
Forrest plot of pulmonary complications in AD Group. AD, arch debranching
Figure S4
Figure S4
Forrest plot of pulmonary complications in ET Group. ET, elephant trunk
Figure S5
Figure S5
Forrest plot of reexploration for bleeding in ET Group. ET, elephant trunk
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